Inspection on 29/01/08 for The Village Care Home

This inspection was carried out on 29th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Village Care Home 27/02/09

The Village Care Home 11/12/08

The Village Care Home 01/02/07

The Village Care Home 23/11/05

The Village Care Home 28/07/05

The Village Care Home 24/11/04

The Village Care Home 30/07/04

The Village Care Home 25/02/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Village Care Home Hylton Bank South Hylton Sunderland SR4 0LL Lead Inspector Sam Doku Unannounced Inspection 29th January to 13 March 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Village Care Home Address Hylton Bank South Hylton Sunderland SR4 0LL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 534 2676 0191 534 1427 thevillagecarehome@googlemail.com The Village Care Home (South Hylton) Limited Miss Tracey McCully Care Home 40 Category(ies) of Dementia (9), Mental disorder, excluding registration, with number learning disability or dementia (9), Old age, not of places falling within any other category (40), Physical disability (1), Physical disability over 65 years of age (6) The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of services only: Care home only – (PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category – Code OP, maximum number of Places: 40 Dementia – Code DE, maximum number of places: 9 Mental disorder, excluding learning disabilities or dementia –Code MD, maximum number of places: 9 Physical disability – Code PD, maximum number of places: 6 Maximum number of service users that can be accommodated is: 40 Date of last inspection 1st February 2007 Brief Description of the Service: The Village Care Home provides personal care for 40 older people over the age of 65 years, some of who may have dementia or mental health needs. It does not provide nursing care and any health needs are dealt with by the Community Nursing Services. Registration includes 6 places for people with a physical disability and as such has designated rooms on the ground floor, which offer easy access to the outside grounds. The house is detached Victorian in construction and two storeys high, with bedrooms being on both ground and first floors. Each floor has a variety of lounge and dining areas. In addition to this there is a large conservatory area on the ground floor. The home provides a designated area for the residents to smoke. The upper floor has a sun terrace, which overlooks a patio area. The interior furnishings of the home are in keeping with the period of the house and due to its age many of the rooms are unique in design and layout. The home is sited on the main road into South Hylton Village, which is close to the metro station, enabling easy access to Sunderland city centre as well as Newcastle and Gateshead. There are some small shops in the village, which include a post office, chemist and general dealers, as well as a social club, all of which are in walking distance of the home. A local bus service can be accessed to the city centre and surrounding areas. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 5 The scale of charges for the home is £402.00 for residential residents and £417.00 for people suffering from dementia. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection was unannounced and started on 29 January 2008. There were four separate visits to the home and the final part of the inspection was concluded with a meeting with the provider on the 13 March to feedback to him on the outcome of the visits. Before the visit the inspector looked at: Information we have received since the last key inspection visit on 1 February 2007; How the home dealt with any complaints & concerns since the last visit; • Any changes to how the home is run; • The provider’s view of how well they care for people, as highlighted in the details provided in the Annual Quality Assurance Assessment (AQUAA); • The views of the residents who use the service and their relatives. During the visits the inspector: • talked to the residents, the manager and care staff; • looked at information about the residents and how well their needs are met; • looked at other records which must be kept; • checked that staff had the knowledge, skills & training to meet the needs of the residents; • looked around the building to make sure it was safe & secure; • checked what improvements had been made since the last visit. All of these activities contributed to the inspection findings. The inspector told the provider what he found. What the service does well: The home is clean and free of unpleasant odour. The residents are supported and encouraged to furnish their rooms with their personal items and this makes the rooms personal and individualised. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 7 The home provides good communal facilities for the residents to use. The residents commented positively on the quality and quantity of the food provided. One resident is supported to maintain contact with others outside of the home. This includes arrangements for him to visit the Stroke Club on a weekly basis. Another resident is supported to receive visits from Age Concern and also to attend the local club once a week. There are good arrangements in place for the management of medicines in the home. The company is good at providing NVQ training to the staff. Staff retention is also good which ensures a stable and consistent approach to the care that the residents receive. There are good systems in place for accounting for the residents’ monies. Residents receive regular visits from their GPs and also visits from district nurses to make sure their healthcare needs are being met. The residents and their relatives commented that the staff treat them with respect and dignity. Comments from the residents and their families and friends were very positive. These include ; “We are well fed here and the food is really nice”. “The staff are kind and would do anything for you”. “No complaints at all, the staff are always there for us”. The relatives comments include; “It is always nice and homely here”. “The place is clean and doesn’t smell”. “The staff are kind and always helpful”. “ I have no concerns at all”. What has improved since the last inspection? Since the last key inspection, the manager has included the address and telephone number of the Commission in the service user guide. Suitable arrangements are now in place to ensure that the residents who require assistance during meal times are appropriately supported in a way that promotes their wellbeing. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 8 What they could do better: The home Statement of Purpose must include a statement about providing respite care. The AQAA states that this service is provided and therefore it needs to be reflected in the Statement of Purpose. The care staff must pay attention to health and safety issues when transporting residents in wheelchair. Although the risk assessment in January 2000 states that the resident wish to be wheeled around in the home without foot rest, except when he goes outside of the home, there has been no further evidence to show that the issue of safety has again been discussed with him in subsequent years. The monitoring of residents weights has not been carried out consistently by the staff. One resident lost a substantial amount of weight in a short space of time but there was no evidence to show what action had been taken by the staff to alert healthcare professionals about this drastic weight loss. Care plans must be regularly reviewed and evaluated to reflect the current care that individuals are receiving. The care plan for one gentleman shows that in the initial stages he required two people to attend to his needs at all time, although currently this is not the case. His care plan failed to highlight the change in his care. One resident did not have a care plan. On the first day of the inspection visit, it was noticed that the residents activities information sheet related to December 2007 and was still posted on the door on the dementia unit. There is a high rate of recorded accidents amongst the residents but there is no system in place for evaluating frequency and type of accidents in the home to see if there is a pattern to some of the accidents. This should be considered as part of the quality assurance system in the home. Of the five staff files examined, it was noticed none of the staff had received formal supervision. Some staff need refresher training on statutory training. Staff induction training records were poorly documented and did not demonstrate the competence levels of the staff after the induction period. All the document examined showed that the entire induction was carried out in one day, but most of these were not dated. Risk assessment for the laundry and the kitchen have been carried out but this has not been dated or signed by the person undertaking the assessment. The laundry was dirty and disorganised. There is a high risk of cross infection in the laundry. The bath mobile hoists were last serviced on 1/2/06. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 9 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Before admission, care needs are fully assessed by the home and also by the social worker. This ensures that the care needs are clearly identified and care plans put in place to meet the needs of the individual. Furthermore the service supports and encourages pre-admission visits to the home by prospective residents and or their relatives. This provides the opportunity for them to assess the home before making their decision about coming to live at the home. EVIDENCE: Full assessments are carried out by the social workers and copies made available to the manager before admissions are arranged. It is the home’s policy to carry out their assessment of the individual in their own setting to The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 12 make sure the home has the necessary skills and facilities to meet the needs of the prospective resident. Two visitors said the assessment process and the opportunity for individuals to visit the home before admission reassured them and the resident, that the home was able to meet their needs. The service encourages prospective residents and/or their relatives to visit the home before admission is arranged. This is the policy of the home and the manager always makes the offer for people to visit the home to see the place for themselves, before making up their minds about coming to live there. Two residents confirmed that this process took place and one gentleman described how the arrangement to visit the home beforehand had made it easier for him to decide to move into the home. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs have been fully assessed but the care plans and daily records do not fully reflect the good care that is being provided. The service users are treated with respect and dignity, thus promoting their selfesteem and wellbeing. EVIDENCE: Residents and their relatives spoke of the good personal care they receive from the staff. They also commented on the regular visits to healthcare professionals including GPs, district nurses, dentists and chiropodists. There are records of visits from healthcare professionals showing how the healthcare needs are being met. The residents look healthy and well cared for and there were no concerns expressed by residents or relatives about the quality of the care they receive. Staff knew the needs of the residents and they were able to describe the detailed care needs of residents when asked about it. One staff The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 14 member commented that, “we know our residents very well and what their needs are”. However, there are serious concerns about the lack of recordings to support the care that individuals receive. The monitoring of residents’ weights have not been carried out consistently by the staff. For one resident, the last weight recording was in March 07 and no indication was given as to why this had ceased. For another resident there was significant weight loss between March 07 and February 08. There was no evidence to show what action had been taken by the staff to alert health professional about this drastic weight loss, neither was there any written record to show that this weight loss had been re-checked by the manager to satisfy herself whether this was a mistake or a genuine weight loss, so that the GP or other healthcare professionals could be alerted. One resident had a fluid balance sheet which started in July 2007 but there was nothing in the care plan showing the reasons why the fluid balance chart was needed. The last care plan for this lady was dated 14/10/05 and there has not been an evaluation of the care plans since that date. One resident did not have a care plan but the manager indicated that the new care plans that she has recently introduced would soon be extended to that resident. The care plan for one gentleman showed that in the initial stages he required two people to attend to his needs at all time. The manager stated that this was no longer the case and that the gentlemen no longer needed two people to see to his needs. It was noticed that the care plan that was written on 13/10/99 has never been reviewed to take account of his changing needs and this old care plan still remains on his file as the current care plan. There is high level of recorded accidents in the home amongst the residents and these are well documented. Three accident books were examined by the inspector. It was noticed that in: • Accident Book 10, there were 50 recorded accidents between 22 January 2007 and 15 June 2007. • In Accident Book 11 There were also 50 recorded accidents between 15 June 2007 and 31 August 2007. • In Accident Book 12 there were 40 recorded accidents between 12 September 2007 and 28 December 2007. The inspector examined the details of the kind of accidents in this period and it was evident that 36 of the 40 recorded accidents involve falls with residents. In view of the high rate of recorded accidents, the home should develop a quality assurance system for evaluating the frequency and type of accidents in the home to see if there is a pattern to some of the accidents, which would determine the form of preventative action that would need to be taken. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 15 The care staff must pay attention to health and safety issues when transporting residents in wheelchair. One gentleman was being transported in a wheelchair that did not have footrest on it. The gentleman’s feet were dangling which could potentially cause an injury to him. However, the risk assessment carried out in January 2000 indicates that he does not wish to use the footrest when being transported within the home except when he is outside. Staff need to review the risk assessment on regular basis to show that the gentleman’s view about not using the foot rest remains consistently the same. There are suitable arrangements in place for the storage and administration of medicines in the home. All the senior staff have received appropriate training in the administration of medicines. The drugs administration system was examined and there were no discrepancies. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are supported to maintain contact with their families, friends and the local community. Such support promotes close relationship with relatives and the community in which they live. Furthermore the service users enjoy regular social and recreational activities which are purposeful and in line with their lifestyles and culture. This promotes their sense of wellbeing and satisfaction. The service users receive a nutritious diet, which contributes to their good health and wellbeing. EVIDENCE: The residents enjoy good recreational activities that include board games, cards, sing-a-longs and one-to-one sessions. The home provides weekly activities so that the residents know what activities are to take place. However, on the first inspection visit it was noticed that the December 2007 activities programme, which was a month out of date, was still on the wall in The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 17 the lounge. This could be confusing for residents who suffer from memory problems. Staff were observed to spend time talking to the residents and engaging people in individual and small group activities. Some residents are supported to continue to various social clubs. Residents who receive this kind of support were very complimentary of the staff for their part in making this happen on a weekly basis. Relatives were very complimentary about the staff and there is obvious good rapport between staff, residents and relatives. Relatives commented that staff are supportive and helpful. Some relatives are actively involved in the care of their family members and this has been beneficial to those residents concerned. The arrangements for serving meals are good. The meals were served in a pleasant and relaxed manner and the residents were given plenty of time to eat their meals. Residents were offered a choice of meals and they commented positively on the nutritious and varied meals that are provided in the home. The residents who require assistance with their meals were supported in a discreet and caring manner. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are policies and procedures in place to ensure that the service users are protected from all forms of abuse. However, the recording systems need to be robust enough to reflect and support care practices. EVIDENCE: The home has good policies and procedures and also good information on adult abuse. The policies and the information are freely available to the staff, residents and visitors to the home. These are placed in parts of the home so that it is accessible to everyone. The Service User Guide and Statement of Purpose have summaries of the complaints procedure. Again, copies of these are available to service users and their relatives and are also displayed in the home. Service users and relatives confirmed that any concerns or complaints they may have would be treated seriously. Staff receive training in protection of vulnerable adults and updated training is also given to make sure the staff are aware of the most recent practice in safeguarding adult procedures. The staff showed good understanding of these The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 19 procedures and showed awareness of the need to protect service users from all forms of abuse. However, some staff could benefit from refresher training. There have been no complaints received since December 2005. The manager confirmed that concerns and complaints are taken seriously and dealt with under the home’s protection of vulnerable person’s procedure. Relatives and visitors confirmed that they have confidence in the complaints system and feel that any concerns would be appropriately dealt with by the home. There are a number of complimentary letters and cards from relatives showing their appreciation of the good quality care provided at the Village Care Home. There are good systems and administrative support in place for managing the residents’ monies. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 25, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers accommodation and an environment that is safe, clean and well maintained. This promotes the general welfare, dignity and comfort of the service users. However, mechanical devices such as both hoists must be regularly serviced to promote the welfare of the residents. The standard of hygiene and cleanliness in the laundry is below acceptable standards and compromises the welfare of the residents. EVIDENCE: The home provides a good standard of accommodation. Bedrooms are individually decorated and reflect individual taste. The residents are The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 21 encouraged to furnish their rooms with personal items, making it a pleasant and familiar environment for them. Access into and within the home is good and meets the needs of those residents who have mobility difficulties or have use of walking aids, such zimmer frames or wheelchairs. All the bedrooms and toilets have suitable locks on the doors to ensure residents privacy. There are sufficient numbers of communal areas for the residents to choose from. These include a range of lounges, dining rooms, and a conservatory. Window restrictors have been fixed to all windows and all radiators have suitable coverings, which ensure security and safety for the residents. Checks of hot water at randomly selected bathrooms confirmed that hot water did not exceed 43°c. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection. However, the general hygiene and cleanliness in the laundry room is not satisfactory. On all three visits to the home, it was noticed that the dirty linen, clothes and other items were lying on the laundry floor. They were not bagged or put in containers until they are ready to be washed. The laundry was dirty and disorganised. The floor, skirting boards, window seal and were dirty. The general cleanliness of the laundry was very poor. Clean clothes were hanging near the entrance of the sluice area. It was noticed that to get into the sluice room with dirty linen, one would have to work one’s way through clean cloths that were hanging and ready to be taken to residents. There were no health and safety notices on display in the laundry room. There was no evidence of COSHH training given to the people who are regularly handling chemicals. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home maintains sufficient staffing levels to meet the needs of the service users. Furthermore good recruitment procedures maintain and promote the safety and welfare of the service users. Staff have good training to equip them in providing good quality care, with the exception of the induction programme which is not detailed enough to give confidence that new staff are initially competent. EVIDENCE: Past rotas show that there are sufficient numbers of staff to meet the care needs of the residents. The home follows the company’s recruitment procedures. Appropriate references have been obtained and the necessary checks have been conducted, including CRB enhanced checks. Staff confirmed that they have all had CRB checks done on them. This ensures that only suitable careers are employed. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 23 The training provided for the staff includes moving and handling, first aid, fire safety training, food hygiene, falls prevention and protection of vulnerable adults awareness training. Refresher training is required with some care staff. The induction records are poorly documented and do not demonstrate to the trainer that the trainee is competent. The induction files showed that the entire induction was carried out in a single day and most of these were not dated. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are good care practices in place that protect the health and safety and welfare of the residents and the staff. However, the lack of servicing arrangements for some lifting devices potentially compromises the safety of the residents. The lack of one-to-one supervision of the carers by the manager also potentially compromises the welfare of the residents as carers’ competency and training needs are not being monitored and reviewed. The home has suitable arrangements that ensure that the residents’ monies are safe and properly accounted for. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager has long experience of working in care setting for older people and has the Registered Managers Award. The registered manager runs the home for the benefit of the residents, although the poor record keeping does not provide sufficient written evidence to support the good care that the residents are receiving. The home has a good system in place for managing the personal allowances for the service users. There are good administration support and control systems in place to allow this to happen. Details of purchases and receipts are available to those whose monies are held by the home. The company’s Health and Safety policies remain in place but a large number of these policies have not been reviewed for a number of years and therefore they do not reflect current good practice. There is however evidence that in general staff adhere to proper health and safety practices, which need to be complemented by up-to-date written policies. Servicing records confirm that all portable appliances have been tested. A record is maintained of regular water temperature tests in the home. Regular servicing of fire equipment, gas and electrical appliances have been carried out by the contracted companies. Bath and mobile hoists have not been serviced in line with manufacturer’s recommendations. Other servicing records are up to date. Fire precautions relating to weekly fire alarm testing and record of inspection takes place. There are records in the home indicating fire drills and fire instructions with staff. The fire risk assessment must be reviewed to include indepth assessment of all parts of the home. Staff supervision is grossly lacking and the manager must take account of her responsibilities to ensure that the staff are properly supervised and a record of such supervision are maintained on individual files. The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X 2 X X 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 1 2 The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1)(2) Requirement Assessment of needs must be regularly undertaken by the manager to ensure that the residents current care needs are clearly identified and plans for meeting those needs are formulated. All residents must have properly formulated care plans in place for staff to work to. Environmental risk assessments, including fire risk assessments, must be carried out a person deemed competent to undertake such tasks. Provisions must be made for these to be reviewed regularly. Refresher statutory training must be provided for all those staff who require. Staff induction must be reviewed and to be conducted in a way that meets Sills for Care training standards. Suitable arrangements must be put in place to ensure that all staff receive regular supervision from senior staff who are competent to undertake such DS0000015760.V356947.R01.S.doc Timescale for action 30/06/08 2 3 OP7 OP19 15(1)(2) 23(4)(b) 30/06/08 30/04/08 4 5 OP28 OP30 18(1)(c)(i ) 18(1)(c)(i ) 18(2)(a) 30/06/08 30/04/08 6 OP36 30/04/08 The Village Care Home Version 5.2 Page 28 7 OP38 12(1)(a) 8 OP38 16(2)(j) 9 OP38 23(2)(c) tasks. Staff must promote the safety 30/03/08 and welfare of the residents by ensuring that wheelchairs are used properly to avoid potential of injuries to the people involved. Where the resident had chosen to use wheelchairs without the footrest, then regular risk assessments must take place to and a risk management plan must be put in place. Appropriate steps must be taken 30/06/08 to address the serious health and safety issues relating to cleanliness and the potential for cross infection. Bath and mobile hoist must be 30/04/08 regularly serviced in line with the manufacturer’s recommendations. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP37 OP37 Good Practice Recommendations The activities record should reflect the actual activities that are being provided for the residents. Accident records should be properly monitored as part of the home’s quality assurance system. This would help identify any patterns in the rate and types of accidents in the home. The home’s written policies and procedures should be reviewed and updated to reflect current good practice. All staff who are involved in the handling of hazardous cleaning materials should receive training or instruction in COSHH. 3 4 OP37 OP38 The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Village Care Home DS0000015760.V356947.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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